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Professor of Medicine
Chief, Section of Hepatology
Associate Director, Solid Organ Transplantation
Richard B. Capps Chair of Hepatology
Rush University Medical Center
Nancy Reau, MD, has disclosed that she has received consulting fees from AbbVie, Gilead Sciences, and Intercept and funds for research support from Abbott.
In the backdrop of the COVID-19 pandemic, the WHO hepatitis C elimination target of 2030 seems more unattainable than ever before. However, with innovation, the Digital International Liver Conference 2020 successfully featured several examples of triumph over HCV, giving us all hope that efforts to control viral hepatitis will continue despite the unpredictable environment COVID-19 has thrown us into.
First, micro-elimination targets might be more attainable than aiming for elimination over a large, diverse geographic area (eg, state level). Incarceration is a well recognized risk factor for HCV; however, implementing the care cascade in this population requires investment on multiple levels. Cabezas and colleagues (abstract AS040) presented data from the systematic registry of the informatic database of Health Penitentiary Coordination Department of Spain, which described HCV screening and treatment rates approximating those recommended by the WHO to achieve elimination. The importance of prioritizing treatment for people who are incarcerated irrespective of the degree of hepatic fibrosis was recognized early in Spain, and universal access to direct-acting antiviral (DAA) therapy to reach an ≈100% treatment rate is an important component of HCV elimination efforts in the Spanish prison system. This registry included 71 prisons across Spain, excluding Catalonia, and included data from January 2015 to June 2019. Although screening rates were ≈80% and were lower in locations with high turnover, HCV incidence decreased to 0.29 and HCV viremia prevalence decreased from 11% in 2016 to 1.9% in 2019.These observed decreases were independent of region, type of prison, number of inmates, or turnover rates. This Spanish endeavor shows what can occur when providers and policy work together.
Second, what worked once in HCV may no longer be an effective tactic. Birth cohort screening (HCV antibody testing in those born between 1945 and 1965) is now well established in the minds of clinicians and patients. Best practice alerts are commonly utilized in our electronic medical records, flagging patients for screening if HCV testing has not been performed. Yet strategies to identify and engage patients into a curative care cascade need to change as the population changes. Flemming and colleagues (abstract AS061) projected the disease burden related to cirrhosis in Canada and found that the demographics of liver disease are changing. As expected, nonalcoholic fatty liver disease (NAFLD) cirrhosis is eclipsing viral hepatitis as a cause for liver disease in all cohorts, with an overall increase of 3.3% (95% CI: 2.6-4.1) from 2000 to 2017. Rates of HCV cirrhosis are projected to decline by 46% by 2040 overall, but for women and men born after 1980, they are expected to increase by 46% and 158%, respectively. This means that the systems we have relied on to identify those at higher risk for HCV may no longer capture those at highest risk for both infection and transmission. The authors concluded that wide-scale public health, lifestyle, and pharmacologic interventions are needed to potentially reverse these trends, especially in young adults.
HCV elimination requires buy-in from multiple entities, many of which are trying to balance competing interests. How data are presented is incredibly important, especially when communicating complex datasets to individuals unfamiliar with the nuances of the cascade of care. Recognizing that standard methods of displaying HCV data lacked practical application, Baiano and colleagues (abstract AS041) used a novel graphical display of stacked clustered bar charts and cumulative line graphs to demonstrate general trends and diagnosis-to-cure conversion rates in a cohort of 1164 patients with HCV in Scotland from January 2015 to December 2018. These yearly snapshots presented a visual display of cumulative progression showing that 77.9% of prevalent cases were diagnosed, 71.0% of eligible diagnoses were treated, and 66.6% were cured. The authors found that this provided nuanced information on progress toward WHO elimination targets for each stage of the HCV care cascade, and served as a useful tool for improving local service planning. This concept could easily be applied to other organizations trying to coordinate elimination efforts across diverse but essential community partners.
In summary, these 3 studies offer us tools that we can use to overcome barriers to HCV elimination and to reach our HCV elimination goals.
What steps are you currently taking, or do you plan to take to make progress toward HCV elimination goals in your practice? Please join the conversation by leaving your thoughts and anecdotes in the comments section and by participating in the interactive poll.